Fungal Infections- Exam 2 Flashcards
______ common, normal flora that can become an opportunistic pathogen. What is the MC type?
Candidiasis
Candida albicans
What are some risk factors for Candidiasis?
Chronic disease - chronic kidney disease, cancer, HIV, DM
Medications - corticosteroids, immunosuppressants, broad-spectrum abx
Vascular access - IV drug use, intravascular catheters
Other - recent surgery (especially abdominal), prolonged neutropenia, organ transplant
Candidiasis of the _____ and _____ or the _____ are AIDS-defining opportunistic infections!
mouth
esophagus
lower respiratory tract
______ often seen especially in infants, elderly, DM pts, immune deficiency, or after use of meds like antibiotics/steroids
Oral Candidiasis
Beefy red, edematous mucosa of oral cavity
+/- white plaques on tongue, palate, buccal mucosa, oropharynx
Plaques can be scraped off with a tongue depressor
What am I?
Oral Candidiasis
How is Oral Candidiasis diagnosed?
Often can diagnose clinically
KOH prep - budding yeasts, pseudohyphae
Culture - + for candidal species - more accurate, longer to results
What is the topical treatment for oral candidiasis?
Nystatin (100,000 U/mL) - 5 mL (1 tsp) swish and swallow 4x/day
Clotrimazole troches (10 mg) - 1 troche dissolved orally 5x/day
Miconazole buccal tablet (50 mg) - 1 tablet applied QD
for 7-14 days
What is the systemic treatment for oral candidiasis?
Fluconazole (Diflucan) 200 mg - 1 PO QD
May cut down to 100 mg after day 1
for 7-14 days
What is the alternative treatment for oral candidiasis?
Gentian Violet x 3 days
usually commonly in babies
Esophageal candidiasis is often seen in what type of pt population?
typically in HIV + or other severely
immunosuppressed pts; often also have oral thrush
odynophagia, nausea, reflux, +/- oral thrush
What am I?
How do you diagnosis?
Esophageal Candidiasis
endoscopy
What is the treatment for Esophageal Candidiasis?
Fluconazole (Diflucan) - 400 mg on day 1, then 200-400 mg daily for 14-21 d
Itraconazole (Sporanox) - if resistant to or intolerant of fluconazole
More costly, more nausea, must use solution rather than tablet
OR
IV : Fluconazole (Diflucan) - 400 mg on day 1, then 200-400 mg daily for 14-21 d
If resistant to fluconazole - voriconazole, posaconazole, or an echinocandin
itching, burning, and/or pain around genital area, dyspareunia. thick, white, nonmalodorous, “cottage cheese”. with NO ordor. very itchy
Vulvovaginal Candidiasis
What are some risk factors that increase the rate of Vulvovaginal Candidiasis?
HIV, pregnancy, antibiotic use, uncontrolled DM all up the risk
How do you diagnosis Vulvovaginal Candidiasis?
clinically!
can do KOH prep and culture but not normally
Which vulvovaginal candidiasis treatment comes in ointment form?
terconazole (Terazol) so it stings less when applied
What is the topical treatment for Vulvovaginal Candidiasis?
1, 3, and 7 day regimens available - rx or OTC
Miconazole (Monistat), clotrimazole (Mycelex), terconazole (Terazol)
NEEDS TO BE DOSED AT BEDTIME to prevent leakage
What is the systemic treatment for Vulvovaginal Candidiasis?
Fluconazole (Diflucan) 150 mg - 1 PO x 1 dose
Ibrexafungerp (Brexafemme) 150 mg - 2 PO BID x 2 doses (300 mg q 12 hr)
What is the prophylactic treatment for Vulvovaginal Candidiasis? Alternative?
Azoles - topical PV 1x/week or fluconazole 150 mg 1 PO 1x/wk
Probiotics - questionable benefit, but little harm
Gentian Violet x 1 application, Boric Acid PV x 7 days
______ candida grows well in warm, moist environments (skin folds)
Candidal Intertrigo
What are some risk factors for developing Candidal Intertrigo? Commonly seen where?
obesity, occlusive or tight clothing, sweating, incontinence, DM, immunosuppression, medications
beneath breasts, armpits, inguinal fold, pannus, diaper rash
Erythematous, macerated, well-defined plaques in skin folds
Satellite erythematous papules and pustules
Well defined border with clear transition from red rash to non-effected skin
Candidal Intertrigo
How do you dx Candidal Intertrigo?
clinically!!!
can do
KOH prep (skin scrapings) - budding yeasts, pseudohyphae
Culture - + for candidal species - more accurate, longer to results
What is the treatment for Candidal Intertrigo?
Weight loss, controlling DM, wearing different clothing, etc.
Drying agents - talc, nystatin powder
Topical azoles or nystatin, BID until resolution (usually within 2 weeks)
systemic therapy if severe: Fluconazole 50-100 mg daily or 150 mg once weekly x 2-6 weeks
Tinea capitis is found on the ____
scalp
tinea corporis is found on the ____
body (ringworm)
tinea cruris is found on the ____
groin (jock itch)
tinea pedis is found on the _____
feet- athlete’s foot
tinea versicolor is found on the _____
body- pityriasis versicolor but is not a true tinea and is a dermatophyte
tinea unguium is found on the ____
nail- onychomycosis
superficial mycoses feed off ____. What will a KOH prep reveal?
keratin on the infected skin, nails and hair
segmented hyphae
Single or multiple scaly, circular patches on scalp
Alopecia; may see “black dots” at follicles
(broken-off hairs)
Patches slowly enlarge over time
What am I?
What pt population is it most commonly seen in?
Tinea Capitis
primarily seen in children
How is tinea capitis dx?
clinically
KOH prep and/or culture - usually only in
ambiguous/refractory cases
pruritic, erythematous, scaling, circular or
oval plaque
Center of lesion clears, while a raised, advancing,
scaly red border remains
What am I?
How is it spread?
How it is dx?
Tinea Corporis- ringworm
person-to-person and usually contracted from an animal
clinical presentation, can do KOH prep and culture if unsure
____ is much more common in males. Asymptomatic or itchy
Confined to groin and gluteal cleft
Erythematous lesions with scaly, sharp, spreading
margins; may have central clearing
Tinea Cruris
What are some risk factors for Tinea Cruris? How do you dx?
obesity, DM, immunodeficiency, sweating
clinically
KOH prep/culture
______ teens and adults especially males; seen often in athletes
Spread by contact with spores shed from infected individuals
Shared showers, locker rooms, floors around public pools
May also have tinea cruris, tinea manuum, tinea unguium
Tinea Pedis
Acute exacerbations are self-limiting, but recurrent - often triggered by increased sweating
Will continue indefinitely without treatment!
Itching, burning, stinging of the toes and feet
Erythematous bullae (acute) → scaling, fissuring, macerated skin, thickened plaques
What am I?
How do you dx?
Tinea pedis
clinically
KOH prep/culture
Where do you want to take a swab/prep from if you suspect tinea pedis?
on a not serious looking part
May be falsely negative if taken from macerated skin
What are some risk factors for tinea unguium?
elderly, swimming, tinea pedis,
immunocompromised, DM, psoriasis
thickened nail with
yellowish or brownish discoloration; may separate
from nail bed
What am I?
How do you diagnosis?
Tinea Unguium
KOH prep and/or culture
recommended to r/o other nail disorders
What is the treatment for tinea capitis?
griseofulvin, terbinafine; may consider fluconazole, itraconazole
griseofulvin is first line but some peds dont use it because of the SE and labs that need to be monitored
What is the treatment for tinea corporis?
Topical - azole, butenafine, tolnafate, ciclopirox, or terbinafine QD-BID until cleared (1-3 wks)
Systemic - extensive or refractory - griseofulvin, terbinafine, fluconazole, itraconazole
What is the treatment for tinea cruris?
Topical - azole, butenafine, tolnafate, ciclopirox, or terbinafine until cleared (1 wk); medicated drying powders
Systemic - extensive or refractory - griseofulvin, terbinafine, fluconazole, itraconazole
What is the treatment for tinea pedis? What if it is macerated?
Topical - azole, butenafine, tolnafate, ciclopirox, or terbinafine
If macerated - consider adding aluminum subacetate soaks 20 min BID
Systemic - extensive or refractory - terbinafine, itraconazole, fluconazole, griseofulvin
What is the treatment for tinea unguium?
Topical - efinaconazole, tavaborole, or ciclopirox
Systemic - terbinafine, itraconazole
_____ does NOT work on superficial mycoses infection aka tinea
nystatin
only works on candiasis infections
______ candidemia; may be due to C. albicans or other strains. Severely immunocompromised state; nosocomial infection
Disseminated Candidiasis
Varies greatly - minimal fever to septic shock
May see skin lesions ranging from pustules to nodules
May involve liver, kidney, spleen, eyes, heart
What am I? Dx?
What is the treatment?
Disseminated Candidiasis
blood cultures only + 50% of the time
First line: IV Echinocandins
Capsofungin IV
Mild/moderate disease: fluconazole
must continue for 2 weeks after their last positive blood culture
What is the MC fungal infection in the brown area?
Blastomycosis
What is the MC fungal infection in the yellow/gold area?
coccidioidomycosis
What is the MC fungal infection in the blue area?
Histoplasmosis
What is the MC fungal infection in the purple/pink area?
cryptococcus gattii
_______ inhaled spores from contaminated bird and bat droppings. Begins in lungs, but spreads throughout the body
Histoplasmosis
______ is caused by Histoplasma capsulatum
Histoplasmosis
Where is histoplasmosis commonly found?
Primarily in river valleys (Ohio and
Mississippi River Valleys in US), but
present worldwide
Fever, cough, myalgias, minor chest pain - almost never fatal
Mild flu-like illness to severe pneumonia - 1 week to 6 months
asymptomatic or mild; often found through incidental x-ray findings of pulmonary and/or splenic calcification; may see “eggshell” lymph node calcification
Histoplasmosis
_____ often in epidemics after soil with bird or bat droppings is disturbed. think moving dirt around on a construction site
Acute pulmonary histoplasmosis
In immunocompromised pts:
Fever, cough, dyspnea, weight loss, prostration, oropharyngeal ulcers
Multiple organ system involvement - hepatomegaly, splenomegaly, GI inflammation, adrenal insufficiency, bone marrow suppression, CNS infection
Can have fulminant, septic shock-like presentation progressing to death without tx
Progressive disseminated histoplasmosis
What does the CXR of a pt with histoplasmosis look like?
Military infiltrates and mediastinal LAN
What are the 4 major forms of histoplasmosis?
Acute pulmonary histoplasmosis
Chronic pulmonary histoplasmosis
Complications of histoplasmosis
Progressive disseminated histoplasmosis
Older pts with underlying chronic lung disease
Pts are not necessarily immunosuppressed!
What am I?
What does the CXR look like?
Chronic pulmonary histoplasmosis
apical cavities, chronic infiltrates, pulmonary nodules
_____ persistent mediastinal LAN and fibrosis of the mediastinum. Often seen in what condition?
Granulomatous mediastinitis
Complications of histoplasmosis
Granulomatous mediastinitis
Leads to compromise of pulmonary vascular structures
Superior vena cava syndrome, esophageal constriction
What am I?
Complications of histoplasmosis
What form of histoplasmosis?
acute pulmonary histoplasmosis with mild diffuse inflitration
What form of histoplasmosis?
Disseminated Histoplasmosis with
diffuse interstitial alveolar infiltrates
What form of histoplasmosis?
NONE!
its a normal CXR :)
What form of histoplasmosis?
Calcified healed Histoplasmosis
(asymptomatic patient)
What is the dx?
Fibrosing mediastinitis caused by scar tissue from the histoplasmosis
What lab findings are common with histoplasmosis?
May see anemia of chronic disease, elevated LDH, ferritin, and/or AST
Chronic disease histoplasmosis would want to order a _____
sputum culture
disseminated histoplasmosis would want to order a _____
blood culture
What is the most accurate diagnostic study for histoplasmosis?
bronchoscopy with biospy
What is the treatment for mild/moderate histoplasmosis?
itraconazole (Sporanox), 200-400 mg/day (divided into BID dosing)
weeks to months
What is the treatment for severe histoplasmosis?
IV amphotericin B
Granulomatous/Fibrosing Mediastinitis: may try itraconazole +/- rituximab, +/-
steroids and often times needs surgery
______ Coccidioides immitis or Coccidioides posadasii AKA “Valley Fever”
Coccidioidomycosis
_____ is transmitted through inhaled spores Grows in arid soil - southwest US,
Mexico, Central America
MC - immunocompromised, elderly
Suspect in patients who live or
work in endemic areas
Coccidioidomycosis
What is the incubation period of Coccidioidomycosis?
10-30 days
fever, chills, fatigue, HA, cough, myalgia
May see arthralgia and joint swelling (especially knees and ankles)
Rash (erythema nodosum) - may appear 2-20 days after s/s onset
What am I?
What does the CXR look like?
Coccidioidomycosis
infiltrate, cavities, abscesses, nodules, bronchiectasis - persist in 5%
0.1% of white, 1% of nonwhite patients
Filipinos, blacks, pregnant women, and immunosuppressed at especially high risk
Worsened pulmonary s/s - mediastinal LAD, cough, increased sputum, lung abscesses
Multiorgan involvement - skin, bones, pericardium/myocardium, meningitis
Fungemia is possible; usually followed rapidly by death
What am I? What does the CXR look like?
Disseminated coccidioidomycosis
localized infiltrate, thin-walled cavities, pulmonary abscesses, nodules, mediastinal LAD, pleural effusion
What is erythema nodosum secondary to ?
Coccidioidomycosis infection
What is this? What is the underlying cause?
Erythema Nodosum secondary to Coccidioidomycosis infection
What does the CXR look like on a pt with Coccidioidomycosis?
patchy, nodular and lobar upper lobe pulmonary infiltrates are MC
What is the most reliable way to dx Coccidioidomycosis?
with biopsy and culture - most reliable method
What additional labs might be positive with Coccidioidomycosis?
-may see leukocytosis, eosinophilia
May test for IgM and IgG complement fixation titer; possible to have false negatives
What is the treatment for mild/moderate Coccidioidomycosis?
fluconazole or itraconazole for 4-12 weeks
May try voriconazole, posiconazole if refractory
What is the treatment for severe/disseminated Coccidioidomycosis?
IV amphotericin B x 2-3 weeks, then switched to azole
Abscesses may need surgical management
When would you treat someone prophylaxis for Coccidioidomycosis?
AIDS pts with CD4 count <250 will require maintenance therapy with an azole to prevent relapse
______ inhaled spores
found in moist soil with decomposing
organic matter (wood and leaves)
MC seen in men infected during
outdoor activities for
occupation/recreation
South central and midwestern US
and Canada
Often occurs in immunocompetent (normal) pts
Blastomycosis
______ is caused by Blastomyces dermatitidis
Blastomycosis
chronic pulmonary infection
Flu-like - cough, moderate fever, dyspnea, chest pain
Extrapulmonary involvement - nodular, wart-like skin lesions
S/S may resolve or progress to pneumonia-like illness
purulent sputum production, pleurisy, fever,
chills, wt loss, prostration
What am I?
Blastomycosis
Blastomycosis is asymptomatic in about ____ of cases?
50%
Disseminated Blastomycosis is commonly found in ______ populations. Name some s/s
immunocompromised pts
Bone - ribs, vertebrae MC affected
GU - epididymitis, prostatitis, bladder irritation
Skin - may see nodular lesions as above
In a urine antigen test, ____ has cross reactivity with Histoplasma
Blastomycosis
What does the CXR look like in Blastomycosis?
airspace consolidation or masses are most common
What labs finding are consistent with Blastomycosis?
may see leukocytosis, anemia
Should also order ____ and _____ with blastomycosis
sputum cultures; blood cultures if disseminated
Bronchoscopy - with biopsy and culture
What is the treatment for mild/moderate blastomycosis?
itraconazole (Sporanox) for 2-3 months
What is the treatment for severe/CNS involvement blastomycosis?
IV amphotericin B
____ are inhaled spores found in soil and pigeon dung. Clinically significant disease almost
always in immunocompromised pts
Cryptococcosis
Cryptococcus neoformans is commonly found ____
worldwide
Cryptococcus gattii is commonly found ______
tropical regions and Pacific NW
Of the cyrptococcosis varieties _____ may be more likely to infect immunocompetent and more likely
to cause severe disease
C. gattii
**____ is the MC cause of fungal meningitis
Cryptococcosis
ranges from mild to respiratory failure
May see simple nodules or fever, cough, dyspnea, widespread infiltrates
Pulmonary Cryptococcosis
HA followed by altered mental status, fever, CN abnormalities
Meningeal signs - often absent, especially in HIV+
cryptococcosis meningitis
nodular lesions that may mimic bacterial cellulitis is often found in immunocompromised pts with _____
Cryptococcosis
If you suspect Cryptococcosis want to order ????
serum: test for cryptococcal antigens
Cultures - sputum, blood, and/or urine cultures may be helpful
Bronchoscopy - with culture of sputum
CSF - budding, encapsulated yeast; + cryptococcal antigen
What is the treatment for pulmonary Cryptococcosis?
fluconazole (Diflucan) for 6-12 months
HIV patients need continued suppressive therapy
What is the treatment for Cryptococcosis meningitis?
IV amphotericin B plus flucytosine (if tolerated) x 2 weeks
Followed by 8 weeks of fluconazole
Frequent LP or CSF shunting to relieve high CSF pressure if needed
_____ believed to have
airborne transmission
Most individuals have had asymptomatic
infection by a young age
Major patterns of clinical infection:
Epidemics among premature or debilitated
infants in underdeveloped countries
Sporadic cases among older children and adults
with impaired immunity
HIV/AIDS patients
Pneumocystosis
Pneumocystis jirovecii (worldwide
P. carinii is now called _____
Pneumocystis jirovecii
aka Pneumocystosis
_____ abrupt onset of fever, tachypnea, SOB, nonproductive cough
May or may not have bibasilar crackles on exam
Spontaneous pneumothorax is possible
Rapid deterioration and death if not treated
Pneumocystosis
CXR will have diffuse interstitial infiltration; may also see consolidation, nodules, cavitations (5-10% of pts have normal xray)
NO CULTURES!!
Bronchoscopy - with special testing of respiratory specimens
Giemsa, methenamine silver, PCR, monoclonal antibody testing
Pneumocystosis
What is the treatment for Pneumocystosis?
TMP-SMZ (Bactrim) is the drug of choice - x 14-21 days
HIV patients with CD4 <200 need continued suppressive therapy
What is the 2nd line treatment for Pneumocystosis?
primaquine/clindamycin, trimethoprim-dapsone
